GERD treatment apparatus and method

ABSTRACT

An apparatus includes an expandable member. The expandable member is sized to be positionable in a sphincter. An energy delivery device is positioned on a surface of the expandable member. The energy delivery device has a configuration that provides sufficient energy delivery to create lesions in the interior of the sphincter. When the expandable member is removed from the sphincter, the sphincter returns to its closed or contracted configuration.

RELATED APPLICATIONS

This application is a divisional of co-pending U.S. application Ser. No.09/911,874, filed Jul. 24, 2001(now abandoned), which is a continuationof U.S. application Ser. No. 09/007,237, filed Jan. 14, 1998,(nowabandoned).

BACKGROUND OF THE INVENTION

Gastroesophageal reflux disease (GERD) is a common gastroesophagealdisorder in which the stomach contents are ejected into the loweresophagus due to a dysfunction of the lower esophageal sphincter (LES).These contents are highly acidic and potentially injurious to theesophagus resulting in a number of possible complications of varyingmedical severity. The reported incidence of GERD in the U.S. is as highas 10% of the population (Castell D O; Johnston B T: GastroesophagealReflux Disease: Current Strategies For Patient Management. Arch Fam Med,5(4):221-7; (1996 April)).

Acute symptoms of GERD include heartburn, pulmonary disorders and chestpain. On a chronic basis, GERD subjects the esophagus to ulcerformation, or esophagitis and may result in more severe complicationsincluding esophageal obstruction, significant blood loss and perforationof the esophagus. Severe esophageal ulcerations occur in 20-30% ofpatients over age 65. Moreover, GERD causes adenocarcinoma, or cancer ofthe esophagus, which is increasing in incidence faster than any othercancer (Reynolds J C: Influence Of Pathophysiology, Severity, And CostOn The Medical Management Of Gastroesophageal Reflux Disease. Am JHealth Syst Pharm, 53(22 Suppl 3):S5-12 (1996 Nov. 15)).

Current drug therapy for GERD includes histamine receptor blockers whichreduce stomach acid secretion and other drugs which may completely blockstomach acid. However, while pharmacologic agents may provide short termrelief, they do not address the underlying cause of LES dysfunction.

Invasive procedures requiring percutaneous introduction ofinstrumentation into the abdomen exist for the surgical correction ofGERD. One such procedure, Nissen fundoplication, involves constructing anew “valve” to support the LES by wrapping the gastric fundus around thelower esophagus. Although the operation has a high rate of success, itis an open abdominal procedure with the usual risks of abdominal surgeryincluding: postoperative infection, herniation at the operative site,internal hemorrhage and perforation of the esophagus or of the cardia.In fact, a recent 10 year, 344 patient study reported the morbidity ratefor this procedure to be 17% and mortality 1% (Urschel, J D:Complications Of Antireflux Surgery, Am J Surg 166 (1): 68-70; (1993July)). This rate of complication drives up both medical cost andconvalescence period for the procedure and may exclude portions ofcertain patient populations (e.g., the elderly and immuno-compromised).

Efforts to perform Nissen fundoplication by less invasive techniqueshave resulted in the development of laparoscopic Nissen fundoplication.Laparoscopic Nissen fundoplication, reported by Dallemagne et al.Surgical Laparoscopy and Endoscopy, Vol. 1, No. 3, (1991), pp. 138-43and by Hindler et al. Surgical Laparoscopy and Endoscopy, Vol. 2, No. 3,(1992), pp. 265-272, involves essentially the same steps as Nissenfundoplication with the exception that surgical manipulation isperformed through a plurality of surgical cannula introduced usingtrocars inserted at various positions in the abdomen.

Another attempt to perform fundoplication by a less invasive techniqueis reported in U.S. Pat. No. 5,088,979. In this procedure, aninvagination device containing a plurality of needles is insertedtransorally into the esophagus with the needles in a refracted position.The needles are extended to engage the esophagus and fold the attachedesophagus beyond the gastroesophageal junction. A remotely operatedstapling device, introduced percutaneously through an operating channelin the stomach wall, is actuated to fasten the invaginatedgastroesophageal junction to the surrounding involuted stomach wall.

Yet another attempt to perform fundoplication by a less invasivetechnique is reported in U.S. Pat. No. 5,676,674. In this procedure,invagination is done by a jaw-like device and fastening of theinvaginated gastroesophageal junction to the fundus of the stomach isdone via a transoral approach using a remotely operated fasteningdevice, eliminating the need for an abdominal incision. However, thisprocedure is still traumatic to the LES and presents the postoperativerisks of gastroesophageal leaks, infection and foreign body reaction,the latter two sequela resulting when foreign materials such as surgicalstaples are implanted in the body.

While the methods reported above are less invasive than an open Nissenfundoplication, some still involve making an incision into the abdomenand hence the increased morbidity and mortality risks and convalescenceperiod associated with abdominal surgery. Others incur the increasedrisk of infection associated with placing foreign materials into thebody. All involve trauma to LES and the risk of leaks developing at thenewly created gastroesophageal junction.

There is a need in the art for a less invasive GERD treatment apparatusthat does not require major surgical intervention or require theintroduction of foreign materials into the body. Yet another need existsfor a method of treating GERD that does not involve the medical risks ofleakage and infection developing at an artificially createdgastroesophageal junction. Yet another need exists for an apparatus thattreats GERD with minimum trauma to the LES.

SUMMARY OF THE INVENTION

Accordingly, an object of the invention is to provide an apparatus andmethod for the treatment of GERD.

Another object of the invention is to provide an apparatus and method totreat GERD using minimally invasive surgical methods such asnon-percutaneous methods.

Yet another object of the invention is to provide an apparatus andmethod to treat the esophageal sphincters using minimally invasivesurgical methods.

Another object of the invention is to provide an apparatus and method totighten the LES.

A further other object of the invention is to provide an apparatus andmethod to reduce the frequency of spontaneous relaxation and opening ofthe LES.

Yet another object of the invention is to provide an apparatus andmethod to reduce the frequency and severity of gastroesophageal refluxevents.

These and other objects of the invention are provided in an apparatuswith an expandable member sized to be positionable in a sphincter. Theenergy delivery device is coupled to the expandable member and has aconfiguration that controllably produces lesions of a sufficient size,number and configuration in a sphincter so as to create a selectabletightening of the sphincter.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is an illustrated lateral view of the upper GI tract includingthe esophagus and lower esophageal sphincter and the positioning of theGERD treatment apparatus of the present invention the lower esophagealsphincter.

FIG. 2 is a lateral view of the present illustrating apertures in theexpandable member.

FIG. 3 illustrates a lateral view of an embodiment of the invention thatincludes two expandable members and an electrode coupled to a powersource.

FIG. 4 illustrates a lateral view of a proximal fitting and distalsegments of an embodiment of the invention.

FIG. 5 illustrates a lateral view of the deflection mechanism of theinvention.

FIG. 6A illustrates a lateral view of apertures in the expandable memberand conforming member of the invention.

FIG. 6B illustrates a lateral view of a microporous membrane used in thefabrication of the expandable member and conforming members of theinvention.

FIG. 7 is a lateral view illustrating the use of the deflectionmechanism to deflect the expandable member of the present invention.

FIG. 8 is a lateral view illustrating the use of electrolytic solutionto create an enhanced RF electrode.

FIG. 9A is a lateral view illustrating a radial distribution ofelectrodes on the expandable member of the invention.

FIG. 9B is a lateral view illustrating a longitudinal distribution ofelectrodes on the expandable member of the invention.

FIG. 9C is a lateral view illustrating a spiral distribution ofelectrodes on the expandable member of the invention.

FIG. 10 is a lateral view illustrating the placement of electrodes onthe distal segment of an embodiment the invention.

FIG. 11 is a lateral view illustrating the placement of needleelectrodes on the expandable member of an embodiment the invention.

FIG. 12 is a lateral view illustrating the deployment of needleelectrodes into the smooth muscle of the LES.

FIG. 13 is a lateral view illustrating the position of needle electrodesin the distal segment of the expandable member.

FIG. 14 is a flow chart illustrating the GERD treatment method of thecurrent invention.

FIG. 15 A-C are lateral views which illustrate a technique for properpositioning of the GERD treatment apparatus in the LES.

FIG. 16 is a lateral view of sphincter smooth muscle tissue illustratingelectromagnetic foci and pathways for the origination and conduction ofaberrant electrical signals in the smooth muscle of the lower esophagealsphincter.

FIG. 17 is a lateral view illustrating a zone of electrodes of thecurrent invention that comprises a flexible circuit that facilitatescontact with the lower esophageal sphincter.

FIG. 18 is a lateral view of the esophageal wall illustrating theinfiltration of tissue healing cells into a lesion in the smooth tissueof a esophageal sphincter following treatment with the GERD treatmentapparatus of the present invention.

FIGS. 19 a and 19 b are views similar to that of FIG. 18 illustratingshrinkage of the lesion site caused by cell infiltration.

FIG. 20 is a lateral view of the esophageal wall illustrating thepreferred placement of lesions in the smooth muscle layer of aesophageal sphincter.

FIG. 21 is a lateral view illustrating the creation of zones ofdecreased porosity by sealed conforming members of an embodiment of thepresent invention.

FIG. 22 is a lateral view illustrating the ultrasound transducer,ultrasound lens and ultrasound power source of an embodiment of thepresent invention.

FIGS. 23A-D are lateral views of the esophageal wall illustratingvarious patterns of lesions created by the apparatus of the presentinvention.

FIG. 24 is a lateral view of the esophageal wall illustrating thedelivery of cooling fluid to the electrode-tissue interface and thecreation of cooling zones.

FIG. 25 depicts the flow path, fluid connections and control unitemployed to deliver fluid to the electrode-tissue interface andelectrodes.

FIG. 26 is a lateral view illustrating the placement of coolingapertures adjacent to electrodes in the expandable member.

FIG. 27 depicts the flow path, fluid connections and control unitemployed to deliver fluid to the RF electrodes.

FIG. 28 is an enlarged lateral view illustrating the placement ofsensors on the expandable member.

FIG. 29 depicts a block diagram of the feed back control system that canbe used with the GERD treatment apparatus as shown in FIG. 3.

FIG. 30 depicts a block diagram of an analog amplifier, analogmultiplexer and microprocessor used with the feedback control system ofFIG. 29.

FIG. 31 depicts a block diagram of the operations performed in thefeedback control system depicted in FIG. 29.

DETAILED DESCRIPTION

Referring now to FIGS. 1 and 2, one embodiment of GERD treatmentapparatus 10 that is used to deliver energy to a treatment site 12 toproduce lesions 14 in the LES includes a first expandable member 16 withan interior surface 18 and an exterior surface 20. First expandablemember 16, which can also be an energy delivery device support member,is configured to receive an expansion medium 22 that inflates firstexpandable member 16 from a compacted, non-deployed state to a deployedstate. Exterior surface 20 includes a plurality of apertures 24. Uponthe application of sufficient pressure, first expandable member 16 weepsexpansion medium 22 from interior surface 18.

While expandable member 16, with a single interior surface 18, ispreferred, it will be appreciated that expandable member 16 can be madeof different compositions or materials, with one or more open or closedcells or chambers. The plurality of such cells or chambers can becompressed or configured in a small diameter for insertion, and are thenexpanded after insertion to establish the desired electrical contactwith the targeted surface of the esophagus.

Expansion medium 22 may be a gas, fluid or the like. In variousembodiments, the expansion medium 22 can be an electrolytic solution. Inother embodiments, expansion medium 22 can also be a contrast solutionto facilitate imaging of the procedure by fluoroscopy orultrasonography. Yet in other embodiments, GERD treatment apparatus 10can include visualization capability including, but not limited to aviewing scope, ultrasound, an expanded eyepiece, fiber optics (includingillumination and imaging fibers), video imaging, a light source and thelike.

Referring to FIG. 3, a second expandable member 26 can be positioned atleast partially adjacent to first expandable member 16. Secondexpandable member 26 receives at least a portion of the expansion medium22 from interior surface 18.

An electromagnetic energy delivery device 28 is coupled to one of thefirst or second expandable members 16 and 26, respectively, andconfigured to be coupled to a power source 30.

First and second expandable members 16 and 26 are sized to be expandedto sufficiently dilate the esophagus such that all or a portion of theinterior of the lower esophageal sphincter can be accessible to theenergy delivery device 28. Expandable members 16 or 26 can dilate theesophageal sphincter in a range of 5-40 mms. It will be appreciated thatother devices capable of being in confined non-deployed states, duringtheir introduction into the esophagus and thereafter expanded todeployed states at or near the LES, can be utilized. Such devicesinclude, but are not limited to, basket-shaped devices made ofsuperelastic metals such as nitinol.

Referring to FIG. 4, an extension member 32 with a distal segment 34 isconfigured to be coupled to first and/or second expandable members 16and 26. In one embodiment, extension member 32 is rod-like and can bemalleable, flexible, articulated and steerable. In various embodiments,extension member 32 can contain optics, fluid and gas paths, sensor andelectronic cabling. In one embodiment, extension member 32 can be acoil-reinforced multilumen catheter, as is well known to those skilledin the art. Extension member 32 has sufficient length to position thefirst and second expandable members in the LES and/or stomach using atrans-oral approach. Typical lengths include, but are not limited to, arange of 40-180 cms. A proximal fitting 36 of extension member 32 ismaneuverable by a medical practitioner. In one embodiment, extensionmember 32 runs through the center of expandable member 16 and/or 26 anddistal segment 34 that extends distally beyond the most distalexpandable member. Extension member 32 may be attached to a movableproximal fitting 36 used to control deflection of expandable members 16or 26, as is more fully explained herein.

Referring to FIG. 5, expandable members 16 and 26 may be initiallyrolled or folded around extension member 32. Expandable members 16 and26 can be attached to a deflection mechanism 38, which imparts movementof first and second expandable members 16 and 26 when positioned at theLES. In one embodiment, the deflection mechanism can be a pull wireattached to extension member 32 or first expandable member 16 and to amovable proximal fitting 36, as is well known to those skilled in theart.

Formed spring wires can be included in first expandable member 16 toassist in opening it to the deployed position. Optionally positionedproximal fitting 36 contains a variety of actuators which provide aphysician control of GERD treatment apparatus 10, as more fullydescribed hereafter. The actuators can be rocker switches, sliderswitches and the like, as are well known to those skilled in the art. Atleast portions of GERD treatment apparatus 10 may be sufficientlyradiopaque in order to be visible under fluoroscopy and/or sufficientlyechogenic to be visible under ultrasonography.

One embodiment of GERD treatment apparatus 10 is illustrated in FIG. 6A.First expandable member 16 is made of a material that can be aninsulator. For purposes of this disclosure, an insulator is a barrier tothermal or electrical energy flow. In this embodiment, expandable member16 is substantially surrounded by a conforming member 40 which is alsocalled a fluid conduit. Conforming member 40 receives electrolyticsolution from first expandable member 16, heated or not heated, througha plurality of apertures 24 formed in first expandable member 16, andpasses it to conforming member 40. In another embodiment, shown in FIG.6B, first expandable member 16 is made of a microporous material 42 thatdoes not include distinct apertures.

Referring to FIGS. 6A and 6B, conforming member 40 is made of a materialthat permits controlled delivery of the electrolytic solution to thetreatment site 12 through one or more apertures 24. In anotherembodiment, conforming member 40 can be made of microporous material 42that does not include distinct apertures. Extension member 32 with firstand second expandable members, or alternatively with a single expandablemember, is introduced into the esophagus directly, shown in FIG. 1, orthrough the use of another introducer such as an endoscope (not shown),as is more fully described hereafter with first and second expandablemembers 16 and 26 in non-deployed configurations.

Referring to FIG. 7, first expandable member 16 can be deflected fromside to side to facilitate maneuvering through the esophagus andpositioning in the LES. This movement can be imparted by deflectionmechanism 38.

A variety of energy sources can be coupled to the porous membraneincluding, (i) an RF source coupled to an RF electrode, (ii) a coherentsource of light coupled to an optical fiber, (iii) an incoherent lightsource coupled to an optical fiber, (iv) a heated fluid coupled to acatheter with an open channel configured to receive the heated fluid,(v) a heated fluid coupled to a catheter with an open channel configuredto receive the heated fluid, (vi) a cooled fluid coupled to a catheterwith a closed channel configured to receive the cooled fluid, (vii) acooled fluid coupled to a catheter with an open channel configured toreceive the cooled fluid, (viii) a cryogenic fluid, (ix) a resistiveheating source, (x) a microwave source providing energy from 915 MHz to2.45 GHz and coupled to a microwave antenna, (xi) an ultrasound powersource coupled to an ultrasound emitter, wherein the ultrasound powersource produces energy in the range of 300 KHZ to 3 GHz or (xii) amicrowave source. For ease of discussion for the remainder of thisapplication, the energy source utilized is an RF source andelectromagnetic energy delivery device 28 is a single or a plurality ofRF electrodes 44, also described as electrodes 44. However, all of theother mentioned energy sources are equally applicable to GERD treatmentapparatus 10.

For the case of RF energy, RF electrode 44 may operated in eitherbipolar or monopolar mode with a ground pad electrode. In a monopolarmode of delivering RF energy, a single electrode 44 is used incombination with an indifferent electrode patch that is applied to thebody to form the other contact and complete an electrical circuit.Bipolar operation is possible when two or more electrodes 44 are used.Multiple electrodes 44 may be used. Also, electrolytic solution servesas an enhanced RF electrode 44′ when coupled with an RF electrode 44(refer to FIG. 8).

Also when the energy source is RF, power source 30, which will now bereferred to as a RF energy source 30, may have multiple channels,delivering separately modulated power to each electrode 44. This reducespreferential heating that occurs when more energy is delivered to a zoneof greater conductivity and less heating occurs around electrodes 44which are placed into less conductive tissue. If the tissue hydration orthe blood infusion in the tissue is uniform, a single channel RF energysource 30 may be used to provide power for generation of lesions 14relatively uniform in size.

Electric current flowing through targeted smooth muscle tissue causesheating due to resistance of the tissue resulting in injury to thetissue which can be sufficient to cause the death of affected cells,also known as necrosis. For ease of discussion for the remainder of thisapplication, cell injury will include all cellular effects resultingfrom the delivery of energy from the electrode 44 up to and includingcell necrosis. Cell injury can be accomplished as a relatively simplemedical procedure with local anesthesia. In one embodiment, cell injuryproceeds to a depth of approximately 1-4 mms from the surface of themucosal layer.

Referring now to FIGS. 9A-C, electrodes 44 can cover all or a portion ofexpandable members 16 or 26 and/or conforming member 40. Also,electrodes 44 may be distributed in a variety of patterns along anexterior or interior surface of either expandable member 16 or 26 orconforming member 40, in order to produce a desired placement andpattern of lesions 14. Typical electrode distribution patterns include,but are not limited, to a radial distribution 46 (refer to FIG. 9A) or alongitudinal distribution 48 (refer to FIG. 9B). It will be appreciatedthat other patterns and geometries for electrode placement, such as aspiral distribution 50 (refer to FIG. 9C) may also be suitable. In oneembodiment, electrode 44 is positioned on distal segment 34 of extensionmember 32 (refer to FIG. 10). These electrodes may be cooled asdescribed hereafter. Additionally, distal segment 34 may includeapertures 24 for delivery of cooling and electrolytic solution asdescribed hereafter.

Electrodes 44 can have a variety of shapes and sizes. Possible shapesinclude but are not limited to circular, rectangular, conical andpyramoidal. Electrode surfaces can be smooth or textured and concave orconvex. Surface areas can range from 0.1 mm2 to 200 mm2. It will beappreciated that other geometries and surface areas may be equallysuitable. In one embodiment, electrodes 44 can be in the shape ofneedles and of sufficient sharpness and length to penetrate into thesmooth muscle of the esophageal wall. In this case, needle electrodes 52are attached to expandable member 16 or 26 which is located insideconforming member 40 (refer to FIG. 11). During introduction of the GERDtreatment apparatus 10 into the esophagus, needle electrodes 52 remainretracted inside conforming member 40. Once GERD treatment apparatus 10is properly positioned at the treatment site 12, needle electrodes 52are deployed by expansion of expandable member 16 or 26, resulting inprotrusion of needle electrodes 52 through needle apertures 54 inconforming member 40 and into the smooth muscle tissue of the treatmentsite 12 (refer to FIG. 12). In another embodiment, distal segment 34 mayalso contain needle apertures 54 for protrusion of needle electrodes 52into the smooth muscle of the esophageal wall. In this embodiment, shownin FIG. 13 needle electrodes 52 are coupled to an insulated guide wire56 (known to those skilled in the art) which is advanced through a guidewire lumen 58 in extension member 32.

FIG. 14 is a flow chart illustrating one embodiment of the operation ofGERD treatment apparatus 10. In this embodiment, GERD treatmentapparatus 10 is first introduced into the esophagus under localanesthesia. GERD treatment apparatus 10 can be introduced into theesophagus by itself or through a lumen in an endoscope, such asdisclosed in U.S. Pat. Nos. 5,448,990 and 5,275,608, incorporated hereinby reference, or similar esophageal access device known to those skilledin the art. Expandable member 16 or 26 is expanded with the introductionof a fluid or gaseous expansion medium 22, such as an electrolyticsolution, or a combination of both. This serves to temporarily dilatethe esophagus sufficiently to efface a portion of or all of the folds ofthe LES. In an alternative embodiment, esophageal dilation andsubsequent LES fold effacement can be accomplished by insufflation ofthe esophagus (a known technique) using gas introduced into theesophagus through a channel in the GERD treatment device, or anendoscope or similar esophageal access device as described above. Oncetreatment is completed, expandable members 16 or 26 are evacuated offluid or gas and returned to their predeployed state and GERD treatmentapparatus 10 is withdrawn from the esophagus. This results in the LESreturning to approximately its pretreatment state and diameter.

In one embodiment, electrolytic solution is introduced into expandablemember 16 or 26, causing it to become distended and be self-retained inthe esophagus. Expandable member 16 or 26 can also be expandedmechanically through the use of formed spring wires (not shown) usedalone or in combination with a fluid.

Electrolytic solution in expandable member 16 may be heated to atemperature, which can be modified and adjusted as necessary. Forexample, electrolytic solution can be heated and maintained at atemperature between about 65-90° C. It can be initially introduced intofirst expandable member 16 at the higher temperature, or it can beheated to the higher temperature in first expandable member 16. Byproviding a heated electrolytic solution, there is a reduction in theamount of time needed to complete a satisfactory degree of tissue injuryof targeted cells.

It is important to have proper positioning of the expandable members 16and 26 and conforming member 40 in the sphincter during both diagnosisand treatment phases. This can be facilitated by the followingprocedure: (I) carefully advancing one or both of expandable members 16and 26 in an unexpanded state, distal to the lower esophageal sphincter,(ii) expanding the distal one of the two expandable members and (iii)carefully withdrawing GERD treatment apparatus 10 proximally untilresistance is encountered. This procedure is illustrated in FIGS. 15A-C.

The diagnostic phase then begins. This is achieved through a variety ofdiagnostic methods, including, but not limited to, the following: (I)visualization of the interior surface of the esophagus via an endoscopeor other viewing apparatus inserted into the esophagus, (ii)visualization of the interior morphology of the esophageal wall usingultrasonography to establish a baseline for the tissue to be treated,(iii) impedance measurement to determine the electrical conductivitybetween the esophageal mucosal layers and GERD treatment apparatus 10and (iv) measurement and surface mapping of the electropotential of theLES during varying time periods which may include such events asdepolarization, contraction and repolarization of LES smooth muscletissue. This latter technique is done to determine specific sites in theLES to be treated which are acting as foci 60 or pathways 62 forabnormal or inappropriate polarization and relaxation of the smoothmuscle of the LES (Refer to FIG. 16).

In the treatment phase, the delivery of energy of the targeted site canbe conducted under feedback control, manually or a combination of both.Feedback control enables GERD treatment apparatus 10 to be positionedand retained in the esophagus during treatment with minimal attention bythe physician. When positioned at the LES, GERD treatment apparatus 10provides a relatively even flow of heated electrolytic solution tofacilitate the cell injury process. As shown in FIG. 17, GERD treatmentapparatus 10 also may have a plurality of electrodes 44 contained inzones that effectively create a flexible circuit 64 which in turn,facilitates contact of the electrode 44 with all or a portion of theinterior surface areas of the LES. Electrodes 44 can be multiplexed inorder to treat the targeted site or only a portion thereof. Feedback canbe included and is achieved by, (I) visualization, (ii) impedancemeasurement, (iii) ultrasonography, (iv) temperature measurement; and,(v) sphincter contractile force measurement via manometry. The feedbackmechanism permits the selected on-off switching of different electrodes44 of the flexible circuit 64 in a desired pattern, which can besequential from one electrode 44 to an adjacent electrode 44, or canjump around between non-adjacent electrodes 44. Individual electrodes 44are multiplexed and volumetrically controlled by a controller.

The area and magnitude of cell injury in the LES can vary. However, itis desirable to deliver sufficient energy to the targeted treatment site12 to be able to achieve tissue temperatures in the range of 55-95° C.and produce lesions 14 at depths ranging from 1-4 mm from the interiorsurface of the LES. Typical energies delivered to the esophageal wallinclude, but are not limited to, a range between 100 and 50,000 joulesper electrode 44. It is also desirable to deliver sufficient energy suchthat the resulting lesions 14 have a sufficient magnitude and area ofcell injury to cause an infiltration of lesion 14 by fibroblasts 66,myofibroblasts 68, macrophages 70 and other cells involved in the tissuehealing process (refer to FIG. 18). As shown in FIGS. 19A and B, thesecells cause a contraction of tissue around lesion 14, decreasing itsvolume and, or altering the biomechanical properties at lesion 14 so asto result in a tightening of LES. These changes are reflected intransformed lesion 14′ shown in 19 B. The diameter of lesions 14 canvary between 0.1 to 4 mm. It is preferable that lesions 14 are less than4 mm in diameter in order to reduce the risk of thermal damage to themucosal layer. In one embodiment, a 2 mm diameter lesion 14 centered inthe wall of the smooth muscle provides a 1 mm buffer zone to preventdamage to the mucosa, submucosa and adventia, while still allowing forcell infiltration and subsequent tightening on approximately 50% of thethickness of the wall of the smooth muscle (refer to FIG. 20).

In one embodiment, GERD treatment apparatus 10 conforms tightly with theinterior of the esophagus so that all, or nearly all, of the interiorcircumference of a desired segment of the LES is in contact with asurface of conforming member 40. Conforming member 40 is fitted into theentire LES and expandable member 16 does not have to be moved about theesophagus to complete the treatment. Alternatively, GERD treatmentapparatus 10 may not entirely fill the esophagus, and GERD treatmentapparatus 10 is then moved about the esophagus in order to treat all ofthe esophagus, or those sections where tightening of the loweresophageal sphincter is desired.

Conforming member 40 is made of a material that substantially conformsto the surface of the LES and, or other sphincters. This provides betterconformity than the mere use of expandable member 16. As a result, thedelivery of treatment energy to the LES is enhanced. Energy delivery mayalso be enhanced by use of a conducting surface 72 which may cover all,or part of, the exterior of conforming member 40. The surface ofconforming member 40 can be made conductive by a variety of meansincluding, but not limited to chemical coating with a conductivematerial, implantation with conductive ions and application of aconductive film.

Conforming member 40 can have a thickness in the range of about 0.01 to2.0 cm. Conforming member 40 can be made of a foam type material.Suitable materials include, but are not limited to, knitted polyester,continuous filament polyester, polyester-cellulose, rayon, polyamide,polyurethane, polyethylene, silicone, and the like. Suitable commercialfoams include, (i) Opcell, available from Sentinel Products Corp.,Hyannis, Mass. and (ii) UltraSorb, HT 4201 or HT 4644MD from WilshireContamination Control, Carlsbad, Calif. Conforming member 40 hascharacteristics that make it particularly moldable and formable toirregular surfaces. In one embodiment, conforming member 40 is made ofan open cell foam, or alternatively it can be a thermoplastic film suchas polyurethane, low density polyethylene, or it may be a silicone.Additionally, conforming member 40 can be capable of extrudingconductive materials from conforming member 40 itself.

FIG. 21 illustrates that conforming member 40 can be created by sealingtwo smaller conforming members 74 and 76 together. Smaller conformingmembers 74 and 76 are sealed together between individual electrodes 44.This creates a pocket or zone 78. Zone 78 has a lower porosity for theflow of electrolytic solution than non-zone sections 80, e.g., all othersections of conforming member 40 which do not include a zone 78 with anassociated electrode 44. The porosity of non-zone sections 80 is greaterthan the porosity of zones 78.

From a diagnostic standpoint, it is desirable to image the interiorsurface 18 and wall of the LES including the size and position ofcreated lesions 14. It is desirable to create a map of these structureswhich can input to a controller and used to direct the delivery ofenergy to the treatment site. Referring to FIG. 22, this can beaccomplished through the use of ultrasonography (a known procedure)which involves the use of an ultrasound power source 82 coupled to oneor more ultrasound transducers 84 that are positioned in or onexpandable member 16 or 26 or conforming member 40. An output isassociated with ultrasound power source 82 and RF energy source 30.

Each ultrasound transducer 84 can include a piezoelectric crystal 86mounted on a backing material 88 that is in turn attached to expandablemembers 16 or 26 or conforming member 40. An ultrasound lens 90,fabricated on an electrically insulating material 92, is mounted overthe piezoelectric crystal 86 The piezoelectric crystal 86 is connectedby electrical leads 94 to ultrasound power source 82. Each ultrasoundtransducer 84 transmits ultrasound energy through conforming member 40or expandable members 16 or 26 into adjacent tissue. Ultrasoundtransducers 84 can be in the form of an imaging probe such as Model21362, manufactured and sold by Hewlett Packard Company, Palo Alto,Calif. In one embodiment, two ultrasound transducers 84 are positionedon opposite sides of expandable member 16 to create an image depictingthe size and position of lesion 14 in the LES.

It is desirable that lesions 14 are predominantly located in the smoothmuscle layer of esophageal wall at the depths ranging from 1 to 4 mmsfrom the interior surface of the sphincter. However, lesions 14 can varyboth in number and position within the sphincter wall. It may bedesirable to produce a pattern of multiple lesions 14 within theesophageal smooth muscle in order to obtain a selected degree oftightening of the LES. Typical lesion patterns shown in FIGS. 23 A-Cinclude but are not limited to, (i) a concentric circle of lesions 14all at fixed depth in the smooth muscle layer evenly spaced along theradial axis of the LES, (ii) a wavy or folded circle of lesions 14 atvarying depths in the smooth muscle layer evenly spaced along the radialaxis of the LES, (iii) lesions 14 randomly distributed at varying depthsin the smooth muscle, but evenly spaced in a radial direction; and, (iv)an eccentric pattern of lesions 14 in one or more radial locations inthe smooth muscle wall. Accordingly, the depth of RF and thermal energypenetration in the lower esophageal sphincter is controlled andselectable. The selective application of energy to the lower esophagealsphincter may be the even penetration of RF energy to the entiretargeted site, a portion of it, or applying different amounts of RFenergy to different sites depending on the condition of the sphincter.If desired, the area of cell injury can be substantially the same forevery treatment event.

Referring to FIG. 24, it may be desirable to cool all or a portion ofthe area near the electrode-tissue interface 96 before during and afterthe delivery of energy in order to reduce the degree and area of cellinjury. Specifically the use of cooling preserves the mucosal layers andprotects or otherwise reduces the degree of cell damage to cooled zone98 in the vicinity of the lesion 14. This can be accomplished throughthe use of a cooling fluid 100 that weeps out of the expandable members16 and 26 or conforming member 40 which is in fluid communication with acontinuous lumen 102 in extension member 32 that is, in turn, in fluidcommunication with fluid reservoir 104 and a control unit 106, whoseoperation will be described hereafter that controls the delivery of thefluid (Refer to FIG. 25). All or only a portion of electrode 44 may alsobe cooled.

Similarly, it may also be desirable to cool all or a portion of theelectrode 44. The rapid delivery of heat through electrode 44, mayresult in the build up of charred biological matter on electrode 44(from contact with tissue and fluids e.g. blood) that impedes the flowof both thermal and electrical energy from electrode 44 to adjacenttissue and causes an electrical impedance rise beyond a cutoff value seton RF energy source 30. A similar situation may result from thedesiccation of tissue adjacent to electrode 44. Cooling of the electrode44 can be accomplished by cooling fluid 100 that weeps out of expandablemembers 16 and/or 26 and conforming member 40 as described previously.In another embodiment, expandable member 16 may contain a plurality ofcooling apertures 108 adjacent or directed toward electrode 44 toenhance the flow of cooling solution and, or cooling rate of electrode44 and adjacent tissue (refer to FIG. 26). Referring now to FIG. 27,electrode 44 may also be cooled via a fluid channel 110 in electrode 44that is in fluid communication with fluid reservoir 104 and control unit106 via the continuous lumen 102 in extension member 32 as describedpreviously.

As shown in FIG. 28. one or more sensors 112 may be positioned adjacentor on electrode 44 for sensing the temperature of esophageal tissue attreatment site 12. More specifically, sensors 112 permit accuratedetermination of the surface temperature of the esophagus atelectrode-tissue interface 96. This information can be used to regulateboth the delivery of energy and cooling solution to the interior surfaceof the esophagus. In various embodiments sensors 112 can be positionedat any position on expandable members 16 and 26 and conforming member40. Suitable sensors that may be used for sensor 112 include:thermocouples, fiber optics, resistive wires, thermocouple IR detectors,and the like. Suitable thermocouples for sensor 112 include: T type withcopper constantene, J type, E type and K types as are well known thoseskilled in the art.

Temperature data from sensors 112 are fed back to control unit 106 andthrough an algorithm which is stored within a microprocessor memory ofcontrol unit 106. Instructions are sent to an electronically controlledmicropump (not shown) to deliver fluid through the fluid lines at theappropriate flow rate and duration to provide control temperature at theelectrode-tissue interface 96 (refer to FIG. 28).

The reservoir of control unit 106 may have the ability to control thetemperature of the cooling fluid 100 by either cooling the fluid orheating the fluid. Alternatively, a fluid reservoir 104 of sufficientsize may be used in which the cooling fluid 100 is introduced at atemperature at or near that of the normal body temperature. Using athermally insulated reservoir 114, adequate control of the tissuetemperature may be accomplished without need of refrigeration or heatingof the cooling fluid 100. Cooling fluid 100 flow is controlled bycontrol unit 106 or another feedback control system (described herein)to provide temperature control at the electrode-tissue interface 96.

A second diagnostic phase may be included after the treatment iscompleted. This provides an indication of lower esophageal tighteningtreatment success, and whether or not a second phase of treatment, toall or only a portion of the esophagus, now or at some later time,should be conducted. The second diagnostic phase is accomplishedthrough, (I) visualization, (ii) measuring impedance, (iii)ultrasonography or (iv) temperature measurement, (v) measurement of LEStension and contractile force via manometry.

In one embodiment, GERD treatment apparatus 10 is coupled to an open orclosed loop feedback system. Referring now to FIG. 29, an open or closedloop feedback system couples sensor 346 to energy source 392. In thisembodiment, RF electrode 314 is one or more RF electrodes 314.

The temperature of the tissue, or of RF electrode 314 is monitored, andthe output power of energy source 392 adjusted accordingly. Thephysician can, if desired, override the closed or open loop system. Amicroprocessor can be included and incorporated in the closed or openloop system to switch power on and off, as well as modulate the power.The closed loop system utilizes a microprocessor 394 to serve as acontroller, monitor the temperature, adjust the RF power, analyze at theresult, refeed the result, and then modulate the power.

With the use of sensor 346 and the feedback control system a tissueadjacent to RF electrode 314 can be maintained at a desired temperaturefor a selected period of time without impeding out. Each RF electrode314 is connected to resources which generate an independent output. Theoutput maintains a selected energy at RF electrode 314 for a selectedlength of time.

Current delivered through RF electrode 314 is measured by current sensor396. Voltage is measured by voltage sensor 398. Impedance and power arethen calculated at power and impedance calculation device 400. Thesevalues can then be displayed at user interface and display 402. Signalsrepresentative of power and impedance values are received by acontroller 404.

A control signal is generated by controller 404 that is proportional tothe difference between an actual measured value, and a desired value.The control signal is used by power circuits 406 to adjust the poweroutput in an appropriate amount in order to maintain the desired powerdelivered at respective RF electrodes 314.

In a similar manner, temperatures detected at sensor 346 providefeedback for maintaining a selected power. Temperature at sensor 346 isused as a safety means to interrupt the delivery of energy when maximumpre-set temperatures are exceeded. The actual temperatures are measuredat temperature measurement device 408, and the temperatures aredisplayed at user interface and display 402. A control signal isgenerated by controller 404 that is proportional to the differencebetween an actual measured temperature and a desired temperature. Thecontrol signal is used by power circuits 406 to adjust the power outputin an appropriate amount in order to maintain the desired temperaturedelivered at the sensor 346. A multiplexer can be included to measurecurrent, voltage and temperature, at the sensor 346, and energy can bedelivered to RF electrode 314 in monopolar or bipolar fashion.

Controller 404 can be a digital or analog controller, or a computer withsoftware. When controller 404 is a computer it can include a CPU coupledthrough a system bus. On this system can be a keyboard, a disk drive, orother non-volatile memory systems, a display, and other peripherals, asare known in the art. Also coupled to the bus is a program memory and adata memory.

User interface and display 402 includes operator controls and a display.Controller 404 can be coupled to imaging systems, including but notlimited to ultrasound, CT scanners, X-ray, MRI, mammographic X-ray andthe like. Further, direct visualization and tactile imaging can beutilized.

The output of current sensor 396 and voltage sensor 398 is used bycontroller 404 to maintain a selected power level at RF electrode 314.The amount of RF energy delivered controls the amount of power. Aprofile of power delivered can be incorporated in controller 404 and apreset amount of energy to be delivered may also be profiled.

Circuitry, software and feedback to controller 404 result in processcontrol, and the maintenance of the selected power setting that isindependent of changes in voltage or current, and used to change, (i)the selected power setting, (ii) the duty cycle (on-off time), (iii)bipolar or monopolar energy delivery and (iv) fluid delivery, includingflow rate and pressure. These process variables are controlled andvaried, while maintaining the desired delivery of power independent ofchanges in voltage or current, based on temperatures monitored at sensor346.

As illustrated in FIG. 30, current sensor 396 and voltage sensor 398 areconnected to the input of an analog amplifier 410. Analog amplifier 410can be a conventional differential amplifier circuit for use with sensor346. The output of analog amplifier 410 is sequentially connected by ananalog multiplexer 412 to the input of AID converter 414. The output ofanalog amplifier 410 is a voltage which represents the respective sensedtemperatures. Digitized amplifier output voltages are supplied by AIDconverter 414 to microprocessor 394. Microprocessor 394 may be a type68HC11 available from Motorola. However, it will be appreciated that anysuitable microprocessor or general purpose digital or analog computercan be used to calculate impedance or temperature.

Microprocessor 394 sequentially receives and stores digitalrepresentations of impedance and temperature. Each digital valuereceived by microprocessor 394 corresponds to different temperatures andimpedances.

Calculated power and impedance values can be indicated on user interfaceand display 402. Alternatively, or in addition to the numericalindication of power or impedance, calculated impedance and power valuescan be compared by microprocessor 394 with power and impedance limits.When the values exceed predetermined power or impedance values, awarning can be given on user interface and display 402, andadditionally, the delivery of RF energy can be reduced, modified orinterrupted. A control signal from microprocessor 394 can modify thepower level supplied by energy source 392.

FIG. 31 illustrates a block diagram of a temperature/impedance feedbacksystem that can be used to control the flow rate and duration of coolingfluid 100 through continuous lumen 102 to expandable and conformingmembers 16, 26 and 40 and or RF electrode 314. Energy is delivered to RFelectrode 314 by energy source 392, and applied to tissue site 424. Amonitor 416 ascertains tissue impedance, based on the energy deliveredto tissue, and compares the measured impedance value to a set value. Ifthe measured impedance exceeds the set value, a disabling signal 418 istransmitted to energy source 392, ceasing further delivery of energy toRF electrode 314. If measured impedance is within acceptable limits,energy continues to be applied to the tissue. During the application ofenergy sensor 346 measures the temperature of tissue and/or RF electrode314. A comparator 420 receives a signal representative of the measuredtemperature and compares this value to a pre-set signal representativeof the desired temperature. Comparator 420 sends a signal to a flowregulator 422 connected to an electronically controlled micropump (notshown) representing a need for an increased cooling fluid 100 flow rate,if the tissue temperature is too high, or to maintain the flow rate ifthe temperature has not exceeded the desired temperature.

The foregoing description of a preferred embodiment of the invention hasbeen presented for purposes of illustration and description. It is notintended to be exhaustive or to limit the invention to the precise formsdisclosed. Obviously, many modifications and variations will be apparentto practitioners skilled in this art. It is intended that the scope ofthe invention be defined by the following claims and their equivalents.

1. A method of treating a lower esophageal sphincter, comprising:providing an expandable member sized to be positionable at or near alower esophageal sphincter in a compacted condition and being sized andconfigured to expand to an expanded condition to non-permanently dilatethe lower esophageal sphincter, and an energy delivery device coupled tothe expandable member comprising at least one tissue-piercing needleelectrode sized and configured for deployment between a retractedposition and an extended position, coupling a source of radio-frequencyenergy to the energy delivery device, introducing the expandable memberto a tissue region at or near the lower esophageal sphincter in thecompacted condition and with the at least one tissue-piercing needleelectrode in the retracted position, expanding the expandable member tothe expanded condition to dilate the lower esophageal sphincter,deploying the at least one tissue-piercing needle electrode to theextended position to pierce sub-mucosal tissue at or near the loweresophageal sphincter, delivering energy from the source ofradio-frequency energy to the at least one needle-piercing electrode tocause necrosis of the sub-mucosal tissue due to resistance heating at ornear the lower esophageal sphincter and produce at least one sub-mucosallesion to thereby selectively tighten the lower esophageal sphincter,returning the expandable member to the compacted condition and the atleast one tissue-piercing electrode to the retracted position, andremoving the expandable member from the tissue region.
 2. The method ofclaim 1 wherein the energy delivery device includes a plurality oftissue-piercing needle electrodes configured for deployment between aretracted position and an extended position, wherein deploying deploysthe plurality of tissue-piercing needle electrodes to the extendedposition to pierce sub-mucosal tissue at or near the lower esophagealsphincter, and wherein delivering energy delivers radio-frequency energyto the plurality of tissue-piercing needle electrodes to produce aplurality of sub-mucosal lesions.
 3. The method of claim 2 wherein theplurality of sub-mucosal lesions are produced at a fixed depth from themucosal surface layer of no more than about 4 mms.
 4. The method ofclaim 1 wherein the expandable member is a balloon.
 5. The method ofclaim 1 wherein expanding the expandable member to the expandedcondition dilates the lower esophageal sphincter between 5 and 40 mm.